In 2001 the Institute of Medicine (IOM) published the findings of its extensive research on the American healthcare system. In summary, the IOM found that healthcare in America frequently falls short in its ability to translate knowledge into practice and to apply new technology. A central deficiency contributing to this momentous problem is characterized as “episodic care” (e.g., care is limited to patient initiated visits to health care providers) and is compounded by lack of readily available information technology for enabling optimum care processes.
In the predominant model of healthcare delivery in America, patients only receive care if and when they attend an appointment with a healthcare provider. This model has become increasingly problematic as American healthcare has shifted its focus from acute care to the management of chronic conditions. Chronic conditions are now the leading cause of illness, disability, and death. They affect almost half of the US population and account for the majority of healthcare expenses. In caring for chronic conditions there exists the imperative to track patients and pertinent aspects of their care. Unlike acute diseases (e.g., heart attack, pneumonia), chronic diseases (e.g., hypertension, diabetes) are typically asymptomatic for long periods of time, often decades. As a result patients do not have the same impetus to proactively seek medical care. Unfortunately, this neglect of medical care often leads to irreversible consequences (e.g., stroke, blindness, death).
Although information technology in the way of electronic medical records and point-of-care electronic alerts are finding their way into healthcare, these systems do not allow a healthcare provider to easily track and monitor patients in a chronic care model. No electronic system exists to bring patients and needed care to the attention of the healthcare provider in the absence of patient-initiated contact. Historically, a variety of paper-based methods have been employed to track patients and care processes. These methods are inefficient and do not capitalize on information technology. Where electronic patient tracking methods have been employed, the systems have generally not been directed at the level of the healthcare provider and require manual entry of data.
The state of existing methods for patient and care process tracking is exemplified by warfarin, an anticoagulant or “blood thinner,” most typically prescribed to prevent stroke. Warfarin is considered a high-risk medication because under-dosing can result in a higher risk of stroke and over-dosing can result in hemorrhage. As a result of these risks, close monitoring of monthly blood tests is recommended to assure appropriate individualized dosing. Methods for tracking dose and frequency of the needed blood tests range from reliance on patient memory to card filing systems. Electronic tracking systems are stand-alone and do not capitalize on existing information sources, therefore requiring manual data entry of pertinent patient information. In the case where electronic data exists, on-demand queries can produce simple reports, however this is an inefficient method of data tracking.
Although care of chronic diseases is enhanced by tracking of patients and their healthcare data, the improvements in care are not as robust as when healthcare providers are exposed to their individual performance rates. Most chronic disease states have one or more measurable indicators that reflect provider performance and correlate with patient outcomes. National guidelines and published papers provide clear guidance on the choice of measurable indicators. Published evidence supports the hypothesis that feedback of a healthcare provider's performance data, benchmarked against peers' data, promotes better outcomes. The sources of currently available performance data are administrative, primarily billing claims data. Since the primary use for this data is financial, it is often inaccurate and not inclusive of the data elements necessary to characterize patient outcomes and provider performance. Additionally, based on the time cycle of claims acquisition, the feedback of this data is delayed four to eighteen months.
Continuing medical education is a prerequisite for desirable patient health outcomes, but is insufficient in and of itself. When educational forums are provided to healthcare providers, research shows that uptake and retention of information is minimal. However, it is known that when this education is teamed with improved systems of care and/or feedback of performance, care to the patient is significantly improved.